Clinical usefulness of aggressive LDL-lowering therapies using statin, ezetimibe, and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors have been shown in primary as well as in secondary prevention settings. In addition, the idea that the lower, the better story in LDL appears to be true as low as ~30 mg/dl based on recent randomized controlled trials (RCT). Moreover, aggressive LDL-lowering therapies, for either of primary prevention setting, or secondary prevention setting has been shown to be quite effective in Japanese population as well. According to those facts, recent guidelines in Europe, and in Japan suggest to lower LDL cholesterol (LDL-C) level < 70 mg/dl for high-risk patients. However, the attainment rates of such “strict” goals seem to be quite low, probably because most cardiologists still have a feeling of anxiety of extremely low LDL-C level. In this review article, we provide the idea that LDL-C is one of the well-established causal factors for atherosclerotic cardiovascular disease (ASCVD) based on the findings from Mendelian randomization studies in addition to RCT. The beautiful consistency between RCT and Mendel randomization studies have reassured us that the lower, the better, as well as the earlier, the better appear to be true.
Objective: We assessed coronary motion artifacts at various heart rates (HRs) using coronary computed tomography angiography (CCTA) and a phantom; the resulting data were reconstructed using half-scan reconstruction algorithms (HSRA), multi-sector reconstruction algorithms (MSRA), and a novel vendor-specific motion correction algorithm (MCA) introduced to eliminate coronary motion artifacts. Materials and Methods: Using retrospective electrocardiographic (ECG)-gated helical CCTA scans of a cardiac phantom that included branching coronary artery models filled with iodine contrast medium and pulsating at HRs of 50 to 100 beats per minute (bpm), we reconstructed images using HSRA, MSRA, and HSRA combined with MCA during both systole and diastole. On axial images, 2 readers graded image quality focused on coronary motion artifacts at 50 to 100 bpm in 9 segments of the models using a scale from 1 (poor) to 5 (excellent). We then compared the average scores among the 3 algorithms using Kruskal-Wallis and post-hoc tests. Results: At 50 to 60 bpm, there were no significant differences in image quality among the 3 algorithms (P > 0.05). At 70 to 100 bpm, the image quality using MSRA was comparable or better than that of HSRA, and HSRA combined with MCA provided a comparable or better image quality compared with the other 2 algorithms. Conclusion: Coronary motion artifacts are comparable or significantly reduced using HSRA combined with MCA, compared with MSRA.
Introduction: In Japan, the prevalence of unmarried people is increasing. Sometimes, young men who suffer from acute coronary syndrome (ACS) are unmarried. Few reports discussing age at ACS onset and marital status have been reported. Methods and Results: We analyzed 160 patients who came to our hospital with a diagnosis of ACS between January 2017 and September 2018. We excluded 33 men who were over 75 years old. Among the remaining 99 men who were under the age of 75 years, we compared a married group (MG: n = 66) and a single group (SG: n = 33). The clinical characteristics were examined using t-tests. The age at the onset of ACS was significantly younger in the SG than in the MG (62.6±8.6 vs. 57.3±10.0 years; P = 0.007). The low-density to high-density lipoprotein ratio (L/H) was significantly higher in the SG than in the MG (MG: 2.7±0.9 vs. SG: 3.2±1.3; P= 0.027). Using statin was significantly higher in the MG than in the SG (MG: 18.3%±34.2 vs. SG: 6.0%±40.1; P=0.038). There were no differences in hypertension, low density lipoprotein (LDL), high density lipoprotein (HDL), triglyceride, diabetes mellitus, HbA1c, body mass index (BMI), serum creatinine, uric acid and smoking habit between the two groups. There was no difference in the previous percutaneous coronary intervention (PCI), the percentage of ST elevation myocardial infarction (STEMI), peak creatinine kinase-MB (CK-MB), the number of significant fixed stenosis, the percentage of the culprit lesion was LAD (left anterior descending) artery. Multi-variable analysis revealed that marital status was the independent risk factor for young onset of ACS. Conclusion: Single men have a greater risk of early-onset ACS than married men. However, the mechanism for this difference remains unknown, and further studies are required.
Coronary stent infection is extremely rare and difficult to identify. Delay in definite diagnosis often leads to death. We describe a case of stent infection that occurred 8 years after implantation. A 66-year-old woman was admitted to our hospital with high-grade fever. She underwent placement of a bare-metal stent to the right coronary artery at 59 years of age. She also underwent kidney transplantation at 58 years of age and had been taking multiple immunosuppressants. Although whole-body computed tomography (CT) scan at the time of admission found no source of bacterial infection, blood cultures grew Staphylococcus aureus. Brain magnetic resonance imaging revealed multiple cerebral infarctions. Infective endocarditis (IE) was suspected but transthoracic and transesophageal echocardiogram found no evidence of IE. The patient became afebrile after administration of intravenous antibiotics and intravenous immunoglobulin, and blood cultures were negative. However, echocardiogram revealed a decline in left ventricle function, and thereafter, the patient developed acute inferior wall myocardial infarction. Urgent coronary angiography exhibited a large coronary artery aneurysm at the origin of the right coronary artery where a previous coronary stent was implanted, and repeat CT also confirmed a very rapidly developing coronary aneurysm. We performed emergent removal of the mycotic aneurysm along with the infected stent. However, the right heart had been severely damaged prior to surgery. She underwent four days of veno-arterial extracorporeal membrane oxygenation but developed bacterial pneumonia and expired on postoperative day 15. This case highlights the long-term risk of coronary stent infection several years after implantation.
Myocardial infarction can be triggered by emotional arousal, such as that associated with sporting events. We experienced a Japanese case of ST-segment elevation myocardial infarction that developed during a game involving the Japan team in the knockout stage of the Fédération Internationale de Football Association (FIFA) World Cup. A 52-year-old man presented with prolonged chest pain, which developed while watching a live stream of the Japan vs. Belgium match. As Japan is nine hours ahead of Greenwich Mean Time, the live stream started at 3 a.m. in Japan. His chest symptoms occurred immediately after Belgium scored a goal and tied the game at 2-2 in the 74th minute. A diagnosis of inferior ST-segment elevation myocardial infarction was made. Emergency angioplasty was performed without complications and the clinical course was uneventful. The patient was discharged before the final of the 2018 FIFA World Cup in Russia and advised not to watch the final live, because the match was scheduled to be broadcast after midnight in Japan.